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aur+.. <br />Please print or type. Form designed for use on elite 12 writer. <br />FormApproved. QMB No. 2050-0039 <br />UNIFORM H US <br />1, Generator ID Number 11 <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. _n um <br />F S E <br />WASTE MANIFEST <br />CALOM&M. <br />1 <br />(OW) 424-MOO00577-1824 <br />6. Generators Name and mailing Address sSite Address If different than me ngrasa <br />Quik atop Markets, Inc. Quilt Stag► MwItele Inc. x1«148 <br />205 W UNI t lord §t. <br />4W7 Efffrprise Street � <br />Fremont, CA 014538 Lodi. CA 95241 <br />(51 O) 44&2M <br />Generator's Phone; <br />6. Transporter1pen ame U.S. EPA ID Number <br />SELSHIRE CAR0001831013 <br />7. T nsporter 2 Compai Name U.S. EPA ID Number <br />1/6 .rr <br />S. Delilloated TdOlity Nanleand SM Address I UY EPAl m r <br />C*Monno Keerd©on <br />20M N. Aiaomeds St, CATOSM13362 <br />Compton. CAE 27 310? $37:7100 <br />Facility's <br />ge, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />M.Nol. <br />1. UNd1203, Gasoline Mixture, 3, PG 11 <br />134 <br />X <br />� <br />W <br />2. CHIS WASTE STREAM HAS BEEN QUALIFIED <br />OR RECYCLING/TREATMEWATTHE <br />3. <br />CALIFORNIA. THIS FACILITY HAS THE NECESSARY <br />PERMITS TO RECEIVE YOUR WASTE STREAMAS <br />14. QMUFIEa OUR EPA NUMBER IS 000800133FiZ.14.Handling <br />Instructions and Additional Information WEAR ALL APPROPRIATE <br />EROS 128 QUIK STOP CCN:: <br />Gasoline &', *er PROTECTIVE CLOTHING. W9237, <br />�1 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are ciasel8ed, packaged, <br />marked and lebeledlplecerded, and are M all respects in proper condition for transport according to applicable international and national governmental regulations. # export shipment and I am to Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAdmowle lgment of Consent. <br />I cxw* that the waste minimization statement klentlfled in 40 CFR 282,27(a) (if I am a large quantity generator) or (b) (ti I am a small quantity generator) Is true. <br />Genere s nName Signature Month Day Year <br />., 2. <br />18; In tions Shi to <br />❑ Import to U.S. ❑Export from U.S. dL <br />Transporter signature for exports onw; Dat leaving U.S..- <br />.S.:17. <br />17.Transporter A* MAedgment of Matedeb' <br />Transporter I PdnRTyWj0WSignature month y rear <br />(� <br />2 Signature r yy� year <br />18. Discrepancy <br />18a. Discrepancy Indication Speoe❑ Quantity ❑ Type ❑Residue ❑ Partial R*ctlon ❑"Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U,S. EPA ID Number <br />V <br />Facilitys Phone: <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />O <br />t <br />2. 3. <br />4. <br />Designated Fadtity Owner Operator: Certification of reFW of materials covered by the manifest except as noted in Item 188 . <br />' <br />Name signature / �lemorn Day ear <br />EPA Fo 22 (Rev. 3,05) Previous editions are ob _ te. <br />DESIGNATED FACILI TO GENE TOR <br />